Utility of post-intubation chest X-rays in the intensive care unit

Purpose: The purpose of this investigation was to determine the clinical utility and necessity of immediate ("stat") chest X-rays (CXR) following endotracheal intubation by experienced Critical Care personnel. Methods: This was a prospective, observational study of adult patients in a 10 bed Intensive Care Unit and a 9 bed Intermediate Intensive Care Unit. All patients intubated by a Critical Care (CCM) attending or fellow were eligible for inclusion. Following each intubation the operator completed a data collection form which included patient, operator, and procedural details. Predicted CXR findings (tube placement, pulmonary complications) were recorded prior to review of post-intubation films, which were obtained "stat" in accordance with our unit protocol. Films were subsequently reviewed with actual results then entered on the data forms. Results: 105 intubations were performed during the study period. Endotracheal placement was confirmed in all cases by end-tidal CO2 and physical findings. Only 2 intubations were predicted to show incorrect placement on CXR. Actual CXR findings as interpreted by the CCM physicians demonstrated 12 incorrect tube positions: 4 too low (one at the carina) and 8 too high. Four complicated intubations were reported: 3 initial esophageal intubations and 1 clinically observed aspiration. Although radiographically apparent 24 hours later, no pulmonary complications associated with the aspiration were identified on the "stat" CXR. No other clinical complications were noted in these 105 patients. Conclusions: Tube placement was technically incorrect in 12/105 patients by the clinicians' interpretation. However, only 1/105, a carinal tube placement, was significant enough to be potentially deleterious if not corrected acutely. Despite the difficulty in predicting tube malposition clinically, when intubations were performed by experienced personnel, "stat" CXR did not generally reveal data which would require immediate intervention. We conclude that intubations may be followed by routine scheduled CXR if no specific pulmonary complications are suspected and the operator is clinically experienced in the procedure. Clinical Implications: "Stat" CXR for commonly performed procedures increase the general cost of care. In addition, tests unnecessarily ordered "stat" distract personnel from other, potentially more important work. Appropriate limitation of such procedures can clearly result in both cost savings and an overall increase in the quality of care provided.